With the crash of the Asiana 777, we’re hearing a lot about cockpit culture and how communication across a hierarchy sometimes fails, even when the very lives of the folks communicating (or failing to do so) are on the line.  This isn’t a new concept, and isn’t unique to aviation.  Many parallels have been drawn between aviation communication and healthcare team communications, especially when real or perceived hierarchies exist.  One technique used to help trainees speak up across authority gradients is the two-challenge rule.

What is the two-challenge rule? This rule was adapted from aviation and is taught heavily in anesthesiology crisis resource management courses, and was recently featured in the Anesthesia Patient Safety Foundation newsletter.

The Army Aviation Technical Manual describes the two-challenge rule as follows:

The two-challenge rule allows one crew member to automatically assume the duties of another crew member who fails to respond to two consecutive challenges.

For example, the pilot-on-the-controls becomes fixated, confused, task overloaded or otherwise allows the aircraft to enter an unsafe position or attitude. The pilot-not-on-the-controls first asks the pilot-on-the-controls if he is aware of the aircraft position or attitude. If the pilot-on-the-controls does not acknowledge this challenge, the pilot-not-on-the-controls issues a second challenge. If the pilot-on-the-controls fails to acknowledge the second challenge, the pilot-not-on-the-controls assumes control of the aircraft.

Here’s a link to a paper about how to teach anesthesiology residents this art of communication in the interest of patient safety, using simulation. Critical language is not unique to operating room teams, however.  Any healthcare environment is likely to benefit from these techniques.  As we state in the paper, there are a variety of potential barriers to speaking up, including:

  • assumed hierarchy
  • fear of embarrassment of self or others
  • fear of being wrong/concern for reputation
  • fear of retribution
  • natural avoidance of conflict
  • respect for the teacher/student relationship
  • concern over receiving a negative evaluation

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